<p> Appendix: LMWH Obesity Dosing Protocol1 Peak anti-Xa Levels Anti-Xa Level (IU/mL) Hold Next Dose? Dosage Change Next anti-Xa level <0.35 No Increase by 25% Peak level 4 h after next dose 0.35-0.49 No Increase by 10% Peak level 4 h after next dose 0.5-1.0 No No Peak level next day, then peak level in 1 wk after two consecutive normal levels 1.1-1.5 No Decrease by 20% *Trough level before next dose and peak level 4 h after next dose 1.6-2.0 3 h Delay next dose by 3 *Trough level before next hours then decrease by dose and peak level 4 h 30% after next dose >2.0 Until anti-Xa <0.5 U/mL Hold until anti-Xa <0.5 *Trough level before next U/mL. Then decrease by dose and q12h until anti- 40%. Xa <0.5 U/mL Trough anti-Xa Levels Anti-Xa Level (IU/mL) Hold Next Dose? Dosage Change Next anti-Xa Level <0.5 No No Refer to peak anti-Xa recommendations 0.5-0.7 No Decrease by 10% if Trough level before next previous peak is not also dose elevated. If previous peak level is also elevated, follow peak anti-Xa dosing recommendations. >0.7 Yes Change to Q24h dosing if Trough level before next previous peak anti-Xa dose level is not elevated. If patient is already receiving Q24h dosing, call to recommend switching to IV heparin. Peak LMWH anti-Xa levels should primarily be used to make dose adjustments for enoxaparin. Trough LMWH anti-Xa levels should be used to address whether the patient is clearing enoxaparin appropriately or not.</p><p>ALWAYS follow dosing recommendation for PEAK anti-Xa levels. If BOTH peak and trough anti-Xa levels are elevated, follow PEAK anti-Xa level dosing recommendations. If peak anti-Xa level is normal and trough anti-Xa level is elevated, follow trough level dosing recommendations.</p><p>*Trough levels drawn after an elevated peak should be used to make sure that enoxaparin has cleared enough to trough levels before the next enoxaparin dose is administered.</p><p>1. Nomogram adopted from Netescu EA et al. Ann Pharmacother. 2009;43(6):1064-83. Page 1080 copyright 2009, adaptation reprinted by permission of SAGE Publications.</p>